NC Medicaid Clinical Policy Revision Request Form

Providers and external stakeholders may formally submit a request for revision of a NC Medicaid Clinical Coverage Policy through the NC Medicaid website.

The requestor may fill out the below form and email it to: medicaid.policy.revision.request@dhhs.nc.gov as a single file in PDF format with supporting documentation embedded within. Submissions will only be processed if all required information is completed.

NC Medicaid Clinical Policy Revision Request Form

Please check your Spam folder for any responses related to your submission, which will be sent from the medicaid.policy.revision.request@dhhs.nc.gov email address.

When submitting the Clinical Policy Revision Request form, please ensure your submission has sufficient evidence to support the request. NC Medicaid wants to ensure that we are providing the best evidence-based care for our beneficiaries, and there needs to be solid clinical evidence to support coverage of procedure(s), product(s) and/or service(s).

Timeline for Reviews

If you submit a Clinical Policy Revision Request, please note the typical review cadence that is listed below; however, our timeline may be delayed as NC Medicaid works on time-sensitive legislative and department initiatives.

The NC Medicaid team has established the following estimated timeframes for review of submissions:

• Initial Review may take up to 8 weeks: The NC Medicaid team will review to confirm coverage of the submitted revision to NC Medicaid Clinical Coverage Policy.
• Policy Modification and Promulgation (up to 14 months): If the Policy Revision Request is accepted, then the NC Medicaid team will initiate the formal policy modification process. Pending legal review, fiscal impact and other components as required by NCGS §108A-54.2, revision may be implemented.